What is the assessment and treatment plan for a patient diagnosed with osteoporosis?

Assessment and Treatment Plan for Osteoporosis

Bisphosphonates should be used as first-line pharmacologic treatment for patients diagnosed with osteoporosis to reduce fracture risk. 1

Assessment

Risk Stratification

• Perform initial fracture risk assessment including history of symptomatic and asymptomatic fractures, FRAX score (for patients ≥40 years), and BMD with vertebral fracture assessment (VFA) or spine x-rays 1
• Evaluate for clinical risk factors: prior fractures, falls history, low body weight, significant weight loss, parental history of hip fracture, smoking, alcohol use, and comorbidities (inflammatory bowel disease, rheumatoid arthritis, chronic liver/kidney disease) 2
• Assess for secondary causes of osteoporosis including thyroid disease, hyperparathyroidism, hypogonadism, malabsorption, and medications (especially glucocorticoids) 1
• Determine fracture risk category:
  • Very high risk: Recent vertebral fractures, hip fracture with T-score ≤-2.5, multiple fractures 2, 3
  • High risk: T-score ≤-2.5, history of fragility fracture, or 10-year fracture risk ≥20% 2
  • Moderate risk: T-score between -1.0 and -2.5 with additional risk factors 1

Treatment Plan

Non-Pharmacologic Interventions

• Recommend adequate calcium intake (1000-1200 mg daily) and vitamin D (600-800 IU daily) 1, 2
• Prescribe weight-bearing and muscle resistance exercises (e.g., squats, push-ups) and balance exercises (e.g., heel raises, standing on one foot) 2, 4
• Advise smoking cessation and limiting alcohol consumption 4, 3
• Implement fall prevention strategies 2

Pharmacologic Treatment

First-Line Therapy

• Bisphosphonates (alendronate, risedronate, zoledronate) for both men and women with osteoporosis 1
  • Strong evidence for reducing vertebral, non-vertebral, and hip fractures 1
  • Most favorable balance among benefits, harms, patient values, and cost 1
  • Consider drug holiday after 3-5 years of treatment based on reassessment of fracture risk 1
  • Monitor for rare adverse effects: osteonecrosis of jaw and atypical femoral fractures 1

Second-Line Therapy

• Denosumab for patients with contraindications to or intolerance of bisphosphonates 1
  • Effective at reducing fracture risk 1
  • Important caution: Requires sequential therapy with another antiresorptive agent after discontinuation to prevent rebound bone loss and multiple vertebral fractures 1, 5
  • Monitor for potential side effects: hypocalcemia, skin reactions, infections 5

For Very High-Risk Patients

• Anabolic agents should be considered first for patients at very high fracture risk 1
  • Teriparatide or romosozumab recommended for women with primary osteoporosis at very high risk 1
  • Must be followed by antiresorptive therapy after completion to maintain bone gains 1, 6
  • Teriparatide may increase risk for serious adverse events and withdrawal due to side effects 1, 6
  • Romosozumab followed by alendronate probably does not increase risk for serious harms compared to bisphosphonate alone 1

Special Considerations

Glucocorticoid-Induced Osteoporosis

• For patients on ≥2.5 mg/day of glucocorticoids for >3 months:
  • Perform fracture risk assessment within 6 months of starting therapy 1
  • Oral bisphosphonates strongly recommended for high or very high fracture risk 1
  • Consider anabolic agents (teriparatide) over antiresorptives for very high-risk patients 1

Duration of Therapy

• Reassess need for continued therapy periodically 1
• For bisphosphonates: Consider drug holiday after 3-5 years for patients at lower risk 1
• For denosumab: Do not discontinue without planning sequential therapy with another antiresorptive to prevent rebound fractures 1, 5
• For anabolic agents: Limited to 2 years of use and must be followed by antiresorptive therapy 1, 6

Monitoring

• BMD testing every 1-2 years until stable, then every 2-3 years 1
• Assess for new fractures and compliance with medications 3
• Evaluate for medication side effects at each visit 1, 5, 6
• Consider biochemical markers of bone turnover to assess treatment response in selected cases 4

Common Pitfalls to Avoid

• Undertreatment of osteoporosis despite high fracture risk 7
• Failure to provide sequential therapy after discontinuing denosumab 1, 5
• Inadequate calcium and vitamin D supplementation 2, 4
• Not addressing modifiable risk factors (smoking, alcohol, fall risk) 4, 3
• Stopping bisphosphonates too early or continuing them too long without reassessment 1
• Not considering anabolic therapy for patients at very high fracture risk 1, 2